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Event date
Event time
Date event was discovered
When was the DNS or administrator notified of the event?
Corporation
Facility
Patient’s gender
Patient’s age
Patient’s race
Patient’s ethnicity
Facility contact name
Facility contact email address
Facility contact phone
NCC MERP harm category
Event type
Event location
Level of care
Were there any contributing communication factors?
Were there any contributing device or supply factors?
Were there any contributing human or environmental factors?
Were there any contributing organizational factors?
Were there any contributing patient/resident factors?
Were there any contributing patient/resident management factors?
Were there any contributing policy or procedure factors?
Date event review and analysis completed
Members of the event review and analysis team
Person hours spent in review
Did the review and analysis team have a post-analysis briefing with the interdisciplinary team?
Was the patient or a patient representative given written notification of this event?
Complete account of the event
Cause of the event
Is this a root cause?
Action plan to prevent future event
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